Provider Demographics
NPI:1518755578
Name:ORAL SURGEONS OF OKLAHOMA LLC
Entity type:Organization
Organization Name:ORAL SURGEONS OF OKLAHOMA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PAYOR RELATIONS
Authorized Official - Prefix:
Authorized Official - First Name:CASSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WIETH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-267-8121
Mailing Address - Street 1:1382 S DOUGLAS BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73130-5215
Mailing Address - Country:US
Mailing Address - Phone:405-741-1962
Mailing Address - Fax:
Practice Address - Street 1:1382 S DOUGLAS BLVD
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73130-5215
Practice Address - Country:US
Practice Address - Phone:405-741-1962
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-29
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty